This document provides information on musculoskeletal trauma. It begins with epidemiology statistics on musculoskeletal injuries and discusses the anatomy and physiology of bones, joints, tendons, ligaments and neurovascular structures. It then covers mechanisms of injury, clinical manifestations, emergency management, complications, and nursing management of various musculoskeletal traumas including fractures, dislocations, soft tissue injuries, and pelvic fractures. Specific topics covered in depth include fat embolism, hemorrhage, osteomyelitis, avascular necrosis, crush injuries, compartment syndrome, and rhabdomyolysis.

1. MUSCULOSKELETAL TRAUMA
Linda H. Warren
EdD RN MSN CCRN
NUR 335

2. Objectives
• Identify common MOI associated with musculoskeletal trauma.
• Describe pathophysiological changes related to signs and symptoms.
• Discuss nursing assessment associated with MSKLT trauma patients.
• Identify appropriate nursing diagnosis and expected outcomes for pts.
• Plan appropriate interventions for patients with musculoskeletal trauma
• Evaluate the effectiveness of interventions for musculoskeletal trauma injuries.

3. Epidemiology
• 33 million injuries annually
• Approximately 8,000 deaths per year
• Single or multi-system injuries
▫ Concurrent injuries are common (ex: leg fracture w. head injury)
• Elderly at risk
▫ Poor balance
▫ Medication effects

4. A&P
• Musculoskeletal system:
▫ Bones
▫ Joints
▫ Tendons
▫ Ligaments
• Neurovascular system:
▫ Vessels
▫ Nerves

5. BONES:
• Types
▫ Compact / Spongy (cancellous)
• Classification
▫ Long (femur)
▫ Short (digits)
▫ Flat (sternum)
▫ Irregular (vertebrae)
• Structure
▫ Epiphysis
▫ Epiphyseal plate: growth plate, assess in children
▫ Diaphysis
▫ Medullary cavity: vascular
▫ Articular Cartilage
▫ Periosteum: bone covering, neurovascular

6. • Medullary cavity
contains marrow
which makes RBCs
and stores fat.
Periosteum is
neurovascular

7. JOINTS
• Fibrous
▫ Little or no movement
• Cartilaginous
▫ Slight movement
• Synovial
▫ Freely movable
▫ Arm, wrist, elbow

8. TENDONS & LIGAMENTS:
• Tendons
▫ Thick white fibrous
▫ Collagen fibers / tensile strength
▫ Extension / Flexion
• Ligaments
▫ Bands of fibrous connective tissue
▫ Elastic fibers provide stretch
▫ Stabilize joints
▫ Assist with movement
• Skeletal (striated) Muscle
▫ Voluntary muscles
▫ Fuse with tendon fibers
▫ Insert into bone
▫ Covered by fascia

9. Neurovascular
• Small blood vessels permeate bone
and periosteum.
• Medullary Artery (I.O. access)**
• Nerves:
▫ Distributed through periosteum
▫ Accompany arteries
▫ Transmit impulses
I.O. ACCESS SITES

10. PELVIS
• Weight bearing structure.
• Provides protection to lower abdominal viscera.
• Pelvic ring  formed by sacrum & two innominate bones.
• Stability maintained by ligaments.
• Venous Plexus:
▫ Highly vascular basin
▫ Tearing of vessels  catastrophic hemorrhage  hypovolemic shock
▫ Injury is concealed until bleeding is severe.

11. MOI:
• Intentional / Unintentional
• Blunt
▫ MVCs
▫ Pedestrian injury
▫ Falls
▫ Assaults (direct blows)
▫ Forced flexion / hyperextension
▫ Rotational / twisting forces
• Penetrating
▫ Gunshot / Stabbing / Blast
• Other
▫ Pathological
▫ Seizures (rigidity in tonic phase can cause fractures)
▫ Crush

12. • Blood Loss / Hemorrhage:
▫ Femur: 1500 ml (venous plexus = highly vascular basin)
▫ Humeral: 750 ml
▫ CAUTION: significant blood loss may be concealed.
▫ Multiple Fractures:
 significant blood loss  shock states (mostly hypovolemic)
• Neurological Deficits:
▫ Interrupted conduction pathways
▫ Nerve impulses blocked / diminished:
 due to compressed, torn, or lacerated nerves.
 Partial or complete loss of motor / sensory FX.
▫ Assess pulses above & below injury level for circulation.

13. Musculoskeletal
Injuries

14. Soft Tissue Injuries

15. Soft Tissue Injuries
• Abrasion:
▫ Epidermal/dermal injuries (surface injuries)
▫ Caused by friction, rubbing or scraping.
▫ Rugburn, skid knee on pavement
• Avulsion:
▫ Full thickness skin loss with resulting flap:
unable to approximate wound edges.
▫ Trim skin edges to form a nice approximated
wound edge for suturing.
• Degloving:
▫ Serious avulsion injury.
▫ Results from high energy shearing force.
▫ Tearing large amount of tissue from
underlying vascular supply.

16. • Contusions:
▫ Blood vessel rupture with bleeding soft tissues.
▫ Ecchymosis and hematoma.
▫ Localized pain and swelling
• Lacerations: OPEN WOUND
▫ Causes a tearing or splitting of skin from an external source.
• Punctures: MINIMAL BLEEDING
▫ Wound with a narrow opening that penetrates deep into
soft tissue.
▫ Traps foreign material leading to infection.
 Foot punctures = high rate of infection.
 Keep puncture wound OPEN (prevent it from closing).
 Want puncture to heal from the inside out.
Soft Tissue Injuries

19. MUSCLE STRAINS:
Strain is a “muscle pull”
▫ Cause: overuse, overstretch, or excessive stress.
▫ Microscopic, incomplete muscle tear with
bleeding into tissues.
▫ Soreness, sudden pain, local tenderness with
muscle use or isometric contraction.
▫ “Overuse Syndrome:”
 Cumulative trauma disorder resulting from
prolonged, repetitive forceful or awkward mvmts.
 Ex: carpal tunnel

20. • Injury to ligaments.
• Caused by a wrenching or twisting motion.
 Torn ligament looses ability to stabilize joint
 Blood vessels rupture with edema
 Joint tenderness
 Painful movement
 X-Ray to r/o fracture
SPRAINS:

22. R – REST
I – ICE x 24 - 48 hours
C – Compression
E – Elevation

23. Neurovascular Assessment (5 P’s)
• Pain
• Pallor
• Pulses
• Paresthesia
• Paralysis
***Pain and paresthesia are often
first indicators of fractures.

24. Musculoskeletal Trauma
• Dislocation: surfaces of bone are no longer in anatomic contact.
• Subluxation: partial dislocation of articulating surfaces.
• Avascular Necrosis: delay in reduction of a hip dislocation,
▫ Avascular necrosis of femoral head
▫ Hip dislocations should be reduced within 6-24 hrs.
• Immobilize affected joint
• Surgical reduction
• Analgesia
• Assess neurovascular status

25. Types of Fractures
Compound (open): Skin integrity over or near fracture site is disrupted
Closed: Skin integrity is intact
Complete: Total disruption of bone continuity
Incomplete: Incomplete disruption of bone continuity

26. Types of Fractures
• Comminuted
▫ Splintering of bone into fragments.
• Greenstick
▫ Bone buckles or bends.
▫ Fracture doesn’t go through entire bone.
▫ Common in children r/t immature bone formation.
• Impacted
▫ Distal and proximal sites wedged into each other (not overlapped).
• Displaced
▫ Proximal and distal fracture sites are out of alignment.

27. Clinical Manifestations of Skeletal Fractures:
• Pain / Tenderness
• Loss of function
• Deformity
• Shortening
• Crepitus (air, rice krispies under skin)
• Edema / Swelling
• Discoloration / Ecchymosis
• Muscle spasm
• Closed or Open
• Traction devices: form of immobilization
• Pelvic Fracture: stable vs. unstable
• Shock (hypovolemia)
• Multiple bone fractures cause a large
amount of blood loss.

29. Emergency Management of Fractures:
• Immobilization
• Splinting
• Open Fracture
▫ Cover with clean sterile dressing.
• Reduction – “setting the bone”
▫ Closed reduction: manipulation or manual traction.
▫ Open reduction: surgical approach to set bones,
involves internal fixation devices.
 Pressure areas
 Infection
 Pin-site care

32. Collaborative Management
• Anatomic realignment of bone fragments.
• Immobilization to maintain realignment.
• Restoration of normal or near-normal function.
▫ More prone to developing ARTHRITIS at fracture site.

33. Nursing Management
• Volume Replacement
• Fracture Stabilization
• Pressure Dressings (to stop bleeding)
• Five P’s
▫ Pain
▫ Pallor
▫ Pulse
▫ Paresthesia
▫ Paralysis
***Pain and paresthesia are often first indicators of fractures

35. Pelvic Fractures: Usually result of high energy traumas.
unstable

36. Pelvic Fractures: The more fractures within the pelvis, the
more unstable the injury is. Will require wiring.

37. Pelvic Fractures: High probability of hemorrhage into
pelvic basin / venous plexus (highly vascular)

39. COMPLICATIONS of
MUSCULOSKELETAL INJURIES

43. INFECTION:
• Irrigation (puncture wounds)
• Debridement
• Trimming edges of wound to
allow for suturing.
• Tetanus Toxoid

44. Fat Embolism
• Long bone / Multiple fractures / Crush injuries
• Occurs 24-48 hrs after injury
• Young adults or elderly with proximal femur fractures.
• Fat in medullary cavity can be released…
▫ Fat globules diffuse into blood.
▫ Fat emboli occlude small vessels.
▫ Manifest 24-48 hrs after injury.
• S&S similar to pulmonary emboli
• Altered mental status, confusion
• Non-blancheable petechial rash
• No hemoptysis (not pulmonary)

45. Clinical Manifestations
• Hypoxia (altered ABG’s)
• Tachypnea
• Tachycardia
• Low grade fever
• Dysrhythmias
• Lipuria (fat in urine)
• S&S similar to PE (except no hemoptysis)
• Altered mental status (profound)

47. Management of Fat Emboli
• Fracture Immobilization
• Supplemental Oxygen
• Mechanical Ventilation
• Monitor CV status

48. Associated Vascular Compromise
• DVT
▫ Calf tenderness
▫ Redness
▫ Swelling
▫ Fever
▫ Positive Homan’s sign (toes flexed upwards causes pain)
• Treatment
▫ Early ambulation
▫ Anticoagulation
▫ Pneumatic compression devices
 Knee-high
 Foot

49. Pulmonary Embolus
• Obstruction of pulmonary tree or one
of it’s branches
• Blood clot / thrombus
• Dyspnea / Tachypnea
• Chest pain
• Anxiety
• Fever
• Tachycardia
• Hemoptysis

50. Diagnostic Tests
• Chest x-ray
• Electrocardiogram
• ABGs
• Chest CT
• Spiral CT**
• VQ scan
• Pulmonary angiogram

51. Hemorrhage
• Hypovolemic (traumatic) shock resulting from loss of blood and
extracellular fluid into damaged tissues.
• Occurs more often in fractures of:
▫ Femur (1500 mL blood loss)
▫ Pelvis
▫ Thorax
▫ Spine

52. Management of Hemorrhage
• Blood repletion
• Adequate splinting
• Pain relief
• Prevent further injury and complications
• Cardiac /respiratory / O2-sat monitoring
• Vascular status

53. OSTEOMYELITIS
• Infection of bone
• PATHO:
▫ Staphylococcus Aureus (s. aureus)
▫ Extension of soft tissue infection.
▫ Direct bone contamination from surgery, open
fracture or traumatic injury (knife, gunshot).
▫ Hematogenous spread (blood-borne) from other
sites of infection.

54. OSTEOMYELITIS
• Initial response to infection:
▫ Inflammation
▫ Increased vascularity 
vasodilation  Edema
• 2-3 days:
▫ Thrombosis
▫ Ischemia
▫ Bone necrosis
• Chronic Infection

56. RISK FACTORS:
▫ Elderly
▫ Impaired immunity
▫ Long-term corticosteroid therapy
(ex: COPD)
▫ Comorbidities
 Diabetes
 Rheumatoid Arthritis
 HIV/AIDS
OSTEOMYELITIS

57. S&S:
▫ Septicemia
▫ Pyrexia (fever)
▫ Chills
▫ Tachycardia
▫ Malaise
▫ Pain
▫ Edema
▫ Warm extremity
DIAGNOSIS:
▫ X-ray:
 Irregular calcification
 Bone necrosis
 Peri-ostial elevation r/t bone overgrowth &
new bone formation.
▫ Radioisotope bone scan
▫ MRI
▫ Blood cultures (identify infectious organisms)
▫ Wound cultures
OSTEOMYELITIS

59. • GOAL: prevention!
• ABX: after collection of blood and wound cultures.
▫ Penicillin
▫ Cephalosporins (Ceftriaxone/Rocephin, Cefepime)
• Surgical Debridement: clean out dead tissue
▫ Implanted ABX
• CHRONIC: Sequestrectomy (remove part of bone)
• Wound irrigation
MANAGEMENT of OSTEOMYELITIS:

60. MANAGEMENT of OSTEOMYELITIS:

62. AVASCULAR NECROSIS:
• Tissue death due to anoxia and diminished
blood supply causing bone collapse.
CAUSES:
▫ ETOH abuse (poor NX)
▫ Atherosclerosis
▫ Decompression sickness
▫ Steroid therapy
▫ Hip fracture at femoral neck
▫ Humoral fracture
▫ Jaw fracture
▫ Radiation therapy
▫ Malignant tumors (lymphomas)

63. AVASCULAR NECROSIS:

64. Diagnostics:
▫ X-ray
▫ MRI
Treatment:
• Total hip replacement (THA)
• Bisphosphonates:
- Osteoporosis meds.
- Help to build bone.
• Bone Grafting
MANAGEMENT of AVASCULAR NECROSIS:

65. CRUSH INJURIES:
• Cellular destruction & damage: neurovascular damage.
▫ Pelvis / both lower extremities: life-threatening
• Hemorrhage  Hypovolemic shock
▫ Tissue damage
▫ Destruction of muscle / bone tissue
▫ Fluid loss
• Compartment syndrome
• Infection
• Myoglobinuria / renal dysFX rhabdomyolysis  AKI
• Loss of neurovascular FX DISTAL to injury.

67. COMPARTMENT SYNDROME:
• INCREASED PRESSURE inside a fascial compartment.
• Impaired capillary blood flow  CELLULAR ISCHEMIA.
Internal Sources:
▫ Hemorrhage
▫ Edema
▫ Open or closed fractures
▫ Crush injuries
External Sources:
▫ Skeletal traction
▫ Casts
▫ Air splints
▫ PASG’s

68. COMPARTMENT SYNDROME:
• Compression of nerves, blood vessels, muscle tissue.
▫ Ischemia of muscles and nerves.
• Pain disproportionate to injury.
• Loss of sensation, paresthesia
▫ Numbness and tingling may precede pain.
• Area: edematous / tense
• Increasing muscle weakness
• Pulselessness
• Elevated muscle compartment pressures
▫ Measured with needles.

70. • Elevate extremity ABOVE level of the heart.
• Release restrictive devices:
▫ Casts
▫ Dressings
▫ Clothing
• SURGICAL INT: when conservative measures are
unsuccessful in restoring tissue perfusion within 1 hour.
▫ Fasciotomy: LONGITUDINAL INCISION.
 Takes pressure off of muscle to prevent necrosis.
MANAGEMENT of
COMPARTMENT SYNDROME:

71. LONGITUDINAL INCISION**

72. • Breakdown of muscle tissue that releases a
damaging protein into the bloodstream.
• Muscle breakdown results in the release
of a protein (myoglobin) into the blood.
Myoglobin can damage the kidneys.
• Symptoms include dark, reddish urine,
oliguria, weakness, and myalgia.
• Early TX with aggressive fluid
replacement reduces the risk of AKI.
RHABDOMYOLYSIS

73. RHABDOMYOLYSIS
• Associated with CRUSH INJURIES.
• Pt has been unresponsive for an UNKNOWN
amt of time… be suspicious of rhabdomyolysis.
SYSTEMIC EFFECTS:
• Hypotension
• Sepsis
• Shock
• Acute renal failure (AKI)
• High CK values (>50,000)

74. RHABDOMYOLYSIS
• Muscle destruction releases myoglobin.
• Myoglobin release  blockage of renal tubules  AKI
• Myoglobinuria
• Metabolic acidosis r/t elevated lactic acid levels.
• Hyperkalemia (K+ released from cells)
• Hypocalcemia
• Severe hyponatremia

75. • #1: IVF Resuscitation
• Urine alkalization
• Osmotic diuresis (mannitol)
• Decrease in cast formation
• Cardiopulmonary support
MANAGEMENT of RHABDOMYOLYSIS:

76. TRAUMATIC AMPUTATIONS:
• PARTIAL vs. COMPLETE:
▫ Complete: less active bleeding than with partial amputation.
▫ Partial: irregular tearing  more bleeding can occur.
 Exception: complete avulsive tearing injuries.
• “Preservation of Life Over Limb”  will resuscitate pt before saving limb.
• Guillotine amputations: precise edges
• Avulsive tearing injuries: irregular pattern & edges
S&S:
▫ Pain
▫ Bleeding
▫ Hypovolemic shock

77. • Relieve symptoms
• Improve functional status and QOL
• Surgical amputation is performed at the most distal point
(want to preserve the joint)
Site of amputation:
▫ Circulation: Circulatory status assessed
 Physical exam, Doppler studies, BP, PaO2 and angiography
▫ Functional usefulness
TRAUMATIC AMPUTATIONS:

78. • Conserve extremity length
• Preserve joints
• Fit with prosthesis
Complications:
▫ Hemorrhage
▫ Infection
▫ Skin breakdown
▫ Phantom limb pain
▫ Joint contractures  keep pt mobile to prevent contractures
 The early the pt is mobilizing, the better off they are.
 Goal to get pt into rehab early on.
TRAUMATIC AMPUTATIONS:

79. • Elevate stump.
• Wrap stump in ace
bandage (stump dressing).
• If the dressing becomes
displaced, rewrap the
stump… not an MD order,
nursing can do it. Notify
provider.
• Assess suture line on
stump for infection or
pressure/ irritation from
prosthetic.
• Provide good skin care.
• Ensure prosthesis fits
appropriately.

80. Musculoskeletal Trauma:
Nursing Diagnoses
• Fluid volume deficit r/t hemorrhage.
• Impaired physical mobility r/t fracture, pain, external immobilization devices.
• Risk of infection r/t impaired skin integrity, contamination of wound.
• Impaired skin integrity r/t fracture, impaired mobility, pressure, shear, or friction.
• Pain
• Altered tissue perfusion
• Risk of injury
• Ineffective coping r/t loss of limb
• Altered body image